Palliative treatment of malignant esophagopulmonary fistulas with covered expandable metallic stents. AJR Am J Roentgenol. 2009;193:W278-W282. [PMID: 19770295 DOI: 10.2214/AJR.08.2176]

Esophago-pulmonary artery fistula caused by fish bone impaction

We present a case of a 65-year-old male who experienced posterior sternal pain, accompanied by a week-long fever following the consumption of fish. Computed tomography (CT) examination revealed a fish bone in the middle esophageal, along with a small amount of gas in the mediastinum. A focal pseudoaneurysm formation was observed in the posterior wall of the left pulmonary artery trunk, accompanied by the presence of gas and septic emboli in the main trunk of the left pulmonary artery and some of its branches. Furthermore, distal pulmonary tissue infarction with associated infection was observed (Figure 1A-F). Clinical diagnosis: Esophago-pulmonary artery fistula caused by fish bone impaction. Reports of esophago-pulmonary artery fistulas without involvement of the trachea or bronchi are rare.

Chinese expert consensus on interventional diagnosis and management of acquired digestive-respiratory tract fistulas (second edition)

Acquired digestive-respiratory tract fistulas occur with abnormal communication between the respiratory tract and digestive tract caused by a variety of benign or malignant diseases, leading to the alimentary canal contents in the respiratory tract. Although various departments have been actively exploring advanced fistula closure techniques, including surgical methods and multimodal therapy, some of which have gotten good clinical effects, there are few large-scale evidence-based medical data to guide clinical diagnosis and treatment. The guidelines update the etiology, classification, pathogenesis, diagnosis, and management of acquired digestive-respiratory tract fistulas. It has been proved that the implantation of the respiratory and digestive stent is the most important and best treatment for acquired digestive-respiratory tract fistulas. The guidelines conduct an in-depth review of the current evidence and introduce in detail the selection of stents, implantation methods, postoperative management and efficacy evaluation.

A rare case of lung abscess due to esophageo-pulmonary fistula in asymptomatic carcinoma of esophagus

Acquired esophago-respiratory fistulae are usually esophago-tracheal or esophago-bronchial. Esophago-pulmonary fistulae are rare. Most patients present with cardinal symptoms of esophageal carcinoma or esophago-pulmonary fistula leading to early diagnosis. We report a 56-year-old female with an unusual presentation. She presented with high grade fever with chills and rigor, cough with mucopurulent expectoration and shortness of breath for 15 days without dysphagia, nausea, vomiting or chest pain. Clinically and radiologically a diagnosis of lung abscess was entertained and she was treated with multiple antibiotics without any improvement. Contrast Enhanced Computed Tomography (CECT) chest revealed esophageal malignancy with esophageal-pulmonary fistula communicating with abscess cavity. Patient responded to palliation with self-expandable esophageal stent and drainage of abscess. Although rare, asymptomatic malignant esophageal disease should be considered in the differential diagnosis of lung abscess, which does not follow a usual course. Keywords: Lung abscess, Esophageal cancer, Esophageo-pulmonary fistula, Self expandable metallic stent.

Esophageal Cancer: An Updated Review

The incidence of esophageal cancer (EC) is on the rise. With the distinct subtypes of adenocarcinoma and squamous cell carcinoma comes specific risk factors, and as a result, people of certain regions of the world can be more prone to a subtype. For example, squamous cell carcinoma of the esophagus has the highest incidence in eastern Africa and eastern Asia, with smoking being a major risk factor, whereas adenocarcinoma is more prevalent in North America and western Europe, with gastroesophageal reflux disease being a leading risk factor. With that being said, adenocarcinoma and squamous cell carcinoma have similar and unfortunately poor survival rates, partly because EC is prone to early metastasis given that the esophagus does not have a serosa, as well as the superficial nature of its lymphatics compared with the rest of the gastrointestinal tract. This makes early detection of the utmost importance, and certain patients have been shown to have the benefit of screening/surveillance endoscopies, including those with Barrett's esophagus, lye-induced/caustic strictures, tylosis, and Peutz-Jeghers syndrome. Until treatments significantly improve, identifying EC at the earliest stage will have the best success for patient outcomes, and further elucidation of its pathogenesis and risk factors may lead to identifying other high-risk groups that should be screened.

Fistulas between the Esophagus and Adjacent Vital Organs in Esophageal Cancer

Esophageal fistulas may occur in an advanced stage or as a potentially life-threatening complication of treatment. They can be divided into esophageal-respiratory and esophageal-aorta fistulas. The diagnosis is confirmed with fluoroscopy using dilute barium oral contrast, followed by thin-section computed tomography, which defines the precise location and extent of the fistula. Flexible esophagoscopy and bronchoscopy are required for confirmation and anatomic assessment of the suspected fistula and provide additional information for treatment planning. Contamination is traditionally controlled by surgical exclusion, along with a jejunal feeding tube. Currently, fully covered self-expanding metal stents are the primary treatment option.

Esophagopulmonary fistula causing pulmonary arterial pseudoaneurysms and massive hemoptysis

An esophagopulmonary fistula (EPF) may occur in patients with esophageal carcinoma and result in pulmonary abscess formation. Lung abscesses may in turn cause pulmonary artery (PA) pseudoaneurysms and life-threatening hemoptysis. We report a 59-year-old man with past medical history of metastatic distal esophageal adenocarcinoma who presented with fever, cough, and massive hemoptysis. Imaging evaluation demonstrated an EPF, associated lung abscess, and PA pseudoaneurysms. The presented case illustrates that embolization of PA pseudoaneurysms to prevent bleeding, and endoscopic esophageal covered stent graft placement to divert esophageal contents from the abscess, may facilitate a favorable outcome.

Management of spontaneous and iatrogenic perforations, leaks and fistulae of the upper gastrointestinal tract

Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.

Endoscopic management of perforations, leaks and fistulas

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

Chinese expert consensus on diagnosis and management of acquired respiratory-digestive tract fistulas

Acquired respiratory‐digestive tract fistulas occur with abnormal communication between the airways and digestive tract, causing the interflow of gas and liquid. Despite advances in surgical methods and the development of multimodal therapy in recent years, patients with acquired respiratory‐digestive tract fistulas continue to exhibit unfavorable clinical outcomes. Therefore, in order to guide clinical practice in China, the Respiratory and Cancer Intervention Alliance of the Beijing Health Promotion Association organized a group of experienced experts in the field to develop this consensus document. Based on a study of clinical application and expert experience in the diagnosis and management of acquired respiratory‐digestive tract fistulas at home and abroad, an Expert Consensus was developed. The panelists recruited comprised experts in pulmonology, oncology, thoracic surgery, interventional radiology, and gastroenterology. PubMed, Chinese Biology Abstract, Chinese Academic Journal, and Wanfang databases were used to identify relevant articles. The guidelines address etiology, classification, pathogenesis, diagnosis and management of acquired respiratory‐digestive tract fistulas. The statements on treatment focus on the indications for different procedures, technical aspects, and preprocedural, post‐procedural and complication management. The proposed guidelines for the diagnosis and management of acquired respiratory‐digestive tract fistulas are the first to be published by Chinese experts. These guidelines provide an in‐depth review of the current evidence and standard of diagnosis and management.

Self-expandable metal stent for malignant esophagorespiratory fistula: predictive factors associated with clinical failure

BACKGROUND AND AIMS

Malignant esophagorespiratory fistulas (MERFs) usually are managed by the placement of self-expandable metal stents (SEMSs) but with conflicting results. This study aimed to identify risk factors associated with clinical failure after SEMS placement for the treatment of MERFs.

METHODS

This was a retrospective analysis of a prospectively maintained database used at a tertiary-care cancer hospital, with patients treated with SEMS placement for MERFs between January 2009 and February 2016. Logistic regression was used to identify predictive factors for clinical outcomes and to estimate the odds ratio (OR) and the 95% confidence interval (CI). The Kaplan-Meier method was used for survival analysis, and comparisons were made by using the log-rank test.

RESULTS

A total of 71 patients (55 male, mean age 59 years) were included in the study, and 70 were considered for the final analysis (1 failed stent insertion). Clinical failure occurred in 44% of patients. An Eastern Cooperative Oncology Group (ECOG) performance status of 3 or 4 and fistula development during esophageal cancer treatment were associated with an increased risk of clinical failure. ECOG status of 3 or 4, pulmonary infection at the time of SEMS placement, and prior radiation therapy were predictive factors associated with lower overall survival. Dysphagia scores improved significantly 15 days after stent insertion. The overall stent-related adverse event rate was 30%. Stent migration and occlusion caused by tumor overgrowth were the most common adverse events.

CONCLUSION

SEMS placement is a reasonable treatment option for MERFs; however, ECOG status of 3 or 4 and fistula development during esophageal cancer treatment may be independent predictors of clinical failure after stent placement.

Enteral stents in the management of post-bariatric surgery leaks

A post-bariatric surgery leak is a rare but grave condition and remains every bariatric surgeon's nightmare. Endoscopic therapy with the insertion of self-expandable stents provides an effective minimally invasive approach for the management of leaks. Self-expandable stents, however, are still hampered by their tendency for migration and are not always well tolerated. Recently, double-pigtail stents have been proposed as an alternative endoscopic therapeutic modality. Both types of stents have been shown to be very effective in the management of leaks; however, most studies have pooled gastrointestinal leaks due to different etiologies together. In this article, we review the current status and foreseen innovations in gastrointestinal stenting for post-bariatric surgery leaks.

Endoscopic Management of Esophagorespiratory Fistulas: A Multicenter Retrospective Study of Techniques and Outcomes

BACKGROUND AND AIMS

Esophagorespiratory fistulas (ERF) are a devastating complication of benign and malignant etiologies. ERF are associated with high mortality, short survival, and poor quality of life. We performed a multicenter analysis of patients with ERF undergoing endoscopic treatment.

METHODS

Multicentre retrospective study.

RESULTS

We analyzed 25 patients undergoing 35 procedures over an 8-year period. Our data showed high technical success rates (97.1% of procedures) and with good, but not ideal, clinical success rates (60% of procedures, 80% of patients), which were defined as fistula closure confirmed by radiographic or repeat endoscopic evaluation and/or a lack of recurrent episodes of clinical aspiration to focus on durable ERF closure as opposed to only initial success. Proximal ERF were the most difficult to manage with the lowest overall clinical success rates, highest rates of recurrent aspiration despite endoscopic therapy, highest adverse events, and shortest survival times. Adverse events occurred in 40.0% of our patients and were all minor. Treatment allowed for diet advancement in 75% of patients.

CONCLUSION

This represents the largest recent collection of US data and the first multicenter study evaluating the clinical success of multiple treatment modalities while stratifying data by fistula etiology and esophageal location. The endoscopic approaches detailed in this study offer a minimally invasive and safe choice for intervention with the potential to improve quality of life despite overall suboptimal clinical success and survivorship rates for in with ERF.

Predictor of massive bleeding following stent placement for malignant oesophageal stricture/fistulae: a multicentre study

AIM

To evaluate retrospectively the incidence and predictors of massive bleeding after stent placement for malignant oesophageal stricture/fistulae.

MATERIALS AND METHODS

This retrospective study comprised 519 patients with malignant oesophageal stricture/fistulae that were successfully treated with stent placement at three hospitals. The patients were divided into two groups based on the occurrence of massive bleeding. Univariate and multivariate analysis was performed to evaluate predictive factors of massive bleeding.

RESULTS

Massive bleeding occurred in 54 of 519 patients 1-37 days following stent placement. All of the patients who developed massive bleeding died within 24 hours of the event. Univariate analysis showed massive bleeding was associated with the presence of a concomitant tracheal stent (p<0.001), the existence of concomitant oesophageal fistulae (p<0.001), and prior radiotherapy (p<0.001). Multivariate analysis exhibited that concomitant tracheal stent insertion (odds ratio [OR], 23.134; 95% confidence interval [CI], 9.523-56.199; p<0.001), the presence of oesophageal fistulae (OR, 3.724; 95% CI, 1.677-8.269; p=0.001), and prior radiotherapy (OR, 13.310; 95% CI, 5.464-32.421; p<0.001) were predictors of massive bleeding following stenting.

CONCLUSIONS

The presence of oesophageal fistulae, prior radiotherapy, and concomitant tracheal stent are important factors contributing to bleeding after stenting.

Removable self-expanding metal stents insertion for the treatment of perforations and postoperative leaks of the esophagus

BACKGROUND

Esophageal rupture, spontaneous or iatrogenic, is associated with significant morbidity and mortality. The current study aims at highlighting the various clinical scenarios, where esophageal fully covered self-expanding removable metal stents (FCSEMS) can be used in esophageal rupture.

METHODS

In patients who underwent insertion of FCSEMS between January 2013 and June 2014, all data regarding demographics, indications, insertion, removal, and outcomes were studied retrospectively.

RESULTS

Seven patients underwent the placement of esophageal covered SEMS. Two patients had Boerhaave syndrome, two had leak following the repair of aortic aneurysm, one had extensive esophageal injury following transesophageal echocardiography, one had carcinoma esophagus with tracheaesophageal fistula, and one had dehiscence of esophagogastric anastomosis. Stent insertion was successful in all the patients; one had stent migration which was managed endoscopically. Two patients died due to underlying illness; the rest had successful removal of stents after 8-10 weeks and good outcomes.

CONCLUSION

Esophageal FCSEMS placement is safe and effective modality in management of patients with esophageal rupture.

From esophagus to rectum: a comprehensive review of alimentary tract perforations at computed tomography

Gastrointestinal (GI) tract perforation is a life-threatening condition that can occur at any site along the alimentary tract. Early perforation detection and intervention significantly improves patient outcome. With a high sensitivity for pneumoperitoneum, computed tomography (CT) is widely accepted as the diagnostic modality of choice when a perforated hollow viscus is suspected. While confirming the presence of a perforation is critical, clinical management and surgical technique also depend on localizing the perforation site. CT is accurate in detecting the site of perforation, with segmental bowel wall thickening, focal bowel wall defect, or bubbles of extraluminal gas concentrated in close proximity to the bowel wall shown to be the most specific findings. In this article, we will present the causes for perforation at each site throughout the GI tract and review the patterns that can lead to prospective diagnosis and perforation site localization utilizing CT images of surgically proven cases.

Treatment of esophagopleural fistulas using covered retrievable expandable metallic stents

PURPOSE

To evaluate the clinical efficacy of placement of covered retrievable expandable metallic stents for esophagopleural fistulas (EPFs).

MATERIALS AND METHODS

During the period 1997-2013, nine patients with EPF were treated using covered retrievable expandable metallic stents. The underlying causes of EPF were esophageal carcinoma (n = 6), lung cancer (n = 2), and postoperative empyema for Boerhaave syndrome (n = 1).

RESULTS

Technical success was achieved in eight patients (88.9%). In one patient, incomplete EPF closure was due to incomplete stent expansion. Clinical success, defined as complete EPF closure within 7 days, was achieved in five patients (55.6%). Overall fistula persistence (n = 1) or reopening (n = 4) occurred in five patients (55.6%) 0-15 days after stent placement. The causes of reopening were due to the gap between the stent and the esophagus (n = 3) or stent migration (n = 1). For fistula persistence or reopening, additional interventional management, such as gastrostomy, stent removal, or stent reinsertion, was performed. Stent migration occurred as a complication in one patient with EPF from a benign cause secondary to postoperative empyema. In the eight patients who died during the follow-up period, the mean and median survival times were 78.8 days and 46 days, respectively.

CONCLUSIONS

Placement of a covered expandable metallic esophageal stent for the palliative treatment of EPF is technically feasible, although the rate of clinical success was poor secondary to fistula persistence or reopening. Fistula reopening was caused by the gap between the stent and the esophagus or by stent migration, and additional interventional treatment was useful to ensure enteral nutritional support.

Clinical application of iodine-eluting stent in patients with advanced esophageal cancer

The aim of the present study was to compare the clinical effectiveness of an iodine-eluting stent with a conventional stent in patients with advanced esophageal cancer. Patients with malignant esophageal cancer were randomly assigned to receive a conventional stent (group A) or an iodine-eluting stent (group B). Following implantation, the relief from dysphagia, survival time, routine blood tests, thyroid function examination and complications were compared in the two groups. Groups A and B consisted of 36 and 31 patients, respectively. The mean value that the dysphagia score decreased by was significantly lower in group A (0.83) compared with group B (1.65). The median survival time was longer in group B compared with group A (P=0.0022). No significant differences were observed in the severe complications between the two groups (P=0.084). The iodine-eluting esophageal stent is a relatively safe, feasible and effective treatment for malignant esophageal strictures.

Treatment of malignant esophagorespiratory fistula with metallic stents: An analysis of 21 cases

AIM: To assess the efficacy and safety of metallic stent implantation in the treatment of malignant esophagorespiratory fistula.

METHODS: Twenty-one patients with malignant esophagorespiratory fistula were included in this study. They had pulmonary infection, dystrophia and choke before stent implantation. The stent was introduced under DSA guidance. The success rate, complication rate and curative effect were observed.

RESULTS: Stents were placed successfully in 21 patients. Dysphagia was relieved and the food intake ability was improved in all 21 patients. The mean KPS increased significantly from 40.0 ± 10.8 before stent placement to 70.3 ± 14.0 one week after placement (P < 0.01). The median survive time was 30 weeks.

CONCLUSION: Stent implantation under DSA guidance is a safe and effective treatment for malignant esophagorespiratory fistula, and it can improve patients′ life quality and clinical symptoms.

A case of spontaneous esophagopleural fistula successfully treated by endoscopic stent insertion

The most common cause of esophagorespiratory fistulas (ERFs) is associated with malignancy. The use of self-expandable metal stents is effective for the treatment of malignant ERFs, but benign ERF is rare, which is why its optimal treatment is not defined yet. There have been few reports describing benign esophagopleural fistula and its treatments in South Korea. Here, we report a rare case of spontaneous esophagopleural fistula, which was successfully treated by endoscopic placement of a membrane covered metal stent.

Self-expanding metal stents for palliative treatment of esophageal carcinoma: risk factors for fatal massive bleeding

AIMS

To investigate the risk factors for the development of fatal massive bleeding after esophageal stenting in patients with malignant esophageal lesions.

METHODS

We performed a retrospective analysis of 216 patients with malignant esophageal stricture and esophageal fistulae who received esophageal stents recruited from January 2005 to December 2010 from the Shengjing Hospital of China Medical University. The patients were divided into 2 groups on the basis of the occurrence of fatal upper gastrointestinal bleeding. We evaluated the significance of sex, tumor site, type of stent, stent location, concomitant radiotherapy, esophageal fistulae, and tracheal stent as factors contributing to the development of esophageal bleeding in the 2 groups.

RESULTS

Fatal bleeding developed in 6.9% (15/216) of patients. These patients developed massive hematemesis and died shortly thereafter. The mean and median survival times for the remaining 201 patients were 182.3 and 75.5 days, respectively. The incidence of fatal bleeding was significantly higher among patients with esophageal fistulas and in patients with concomitant tracheal stents compared with those with neither condition. No significant relationship was identified between the incidence of fatal bleeding and age, sex, stent type, stent location, or radiotherapy. Multivariate regression analysis revealed that the presence of esophageal fistula and concomitant tracheal stent were closely related to fatal postoperative bleeding.

CONCLUSIONS

The presence of esophageal fistulae and concomitant tracheal stent are important factors contributing to heavy esophageal bleeding after esophageal stenting.

[Sealing of airway fistulas for metallic covered z-type stents]

背景与目的

气道瘘包括食管气管瘘、支气管胸膜瘘和气管纵隔瘘，临床治疗较为棘手。本文旨在探讨被膜金属支架封堵气道瘘的疗效和安全性。

方法

回顾性分析32例食管气管瘘、5例支气管胸膜瘘和1例气管纵隔瘘患者在气管镜和/或X线透视下放置被膜金属支架。原发病为食管肿瘤26例，肺癌11例，甲状腺癌1例。

结果

38例患者共有46个瘘口，口径0.5 cm-7.0 cm。放置Z型气管被膜金属支架40枚(其中Y形24枚，L形8枚和I形8枚)。食管放置被膜金属支架24枚。46个瘘口封堵疗效：治愈2例(4.3%)，临床完全缓解28例(60.9%)，部分缓解11例(23.9%)，无效5例(10.9%)，有效率为89.1%，中位生存时间为5个月。

结论

被膜金属支架能有效封堵食管气管瘘、支气管胸膜瘘和气管纵隔瘘。应首选气管支架封堵ERF，无效的患者可同时放置食管支架。分叉型气管支架尤其适于隆突周围瘘口。

Intraluminal radioactive stent compared with covered stent alone for the treatment of malignant esophageal stricture

OBJECTIVE

This study was designed to compare the clinical effectiveness of intraluminal radioactive stent loaded with iodine-125 seeds implantation versus covered stent alone insertion in patients with malignant esophageal stricture.

METHODS

We studied two groups of patients with malignant esophageal stricture. Group A comprised 28 patients (19 men and 9 women) who underwent intraluminal radioactive stent loaded with iodine-125 seeds implantation and were followed prospectively. Group B comprised 30 patients (18 men and 12 women) who had previously received covered stent alone insertion; these patients were evaluated retrospectively. There was no crossover between the two groups during follow-up. Informed consent was obtained from each patient, and our institutional review board approved the study. The dysphagia score, overall survival rates, complication rates, and reintervention rates were compared in the two groups.

RESULTS

There were no significant differences between the two groups in terms of baseline characteristics. Stent placement was technically successful and well tolerated in all patients. The dysphagia score was improved in both groups after stent placement. The median survival was significantly longer in group A than in group B: 11 versus 4.9 months, respectively (P < 0.001). The complications of chest pain, esophageal reflux, and stent migration was more frequent in group B, but this difference did not reach statistical significance. There was no statistical difference in reintervention between two groups.

CONCLUSIONS

Intraluminal radioactive stent loaded with iodine-125 seeds implantation was a feasible and practical management in treating malignant esophageal stricture and was superior to covered stent alone insertion, as measured by survival.

Stenting of the upper gastrointestinal tract: current status

Minimally invasive image-guided insertion of self-expanding metal stents in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastroduodenal outlet obstructions. A concise review is presented of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contraindications for treatment are analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology. Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.

Interventional management of esophagorespiratory fistula

An esophagorespiratory fistula (ERF) is an often fatal consequence of esophageal or bronchogenic carcinomas. The preferred treatment is placement of esophageal and/or airway stents. Stent placement must be performed as quickly as possible since patients with ERFs are at a high risk for aspiration pneumonia. In this review, choice of stents and stenting area, fistula reopening and its management, and the long-term outcome in the interventional management of malignant ERFs are considered. Lastly, a review of esophagopulmonary fistulas will also be provided.